Wednesday, August 11, 2010

TOPIC DISCUSSION: Plasma Pheresis and Renal Disease

Plasmapheresis appears to be a useful adjunct to conventional therapy in the treatment of anti-GBM nephritis, severe dialysis-dependent forms of pauciimmune RPGN, cryoglobulinemia, and HUS-TTP, some severe cases of cast nephropathy and in antibody mediated rejection, desensitization and ABOI transplants. But data from controlled trials do not support a role for plasmapheresis in immune complex-mediated RPGN, such as lupus nephritis, and acute allograft rejection. Although Lupus Nephritis with TTP or TMA might benefit from TPE.While data on use of Plasma Pheresis or Apheresis ( TPE) is robust in neurological and hematological diseases, the clinical efficacy of plasmapheresis for many acute renal conditions is still controversial.

The three classic diseases that is worth discussing are ANCA RPGN, anti GBM and

Cast Nephropathy. Lupus Nephritis is also mentioned.

The data on ANCA RPGN is as follows: Based on a recent trial in Europe, the role of TPE in ANCA RPGN is when the crt is >5.7 or they are dialysis dependent. It appears that TPE offers some benefit of disease reversal and better renal outcomes if employed in dialysis dependent forms of the disease.

On the other hand, Anti GBM disease offers the MOST benefit when employed at a time when the patient is NOT dialysis dependent. If they are dialysis dependent, the prognosis of disease doesn't change much with TPE. Pulmonary hemorrhage would be other indication.

In terms of Cast Nephropathy, it is controversial. A study in 2005 showed that patients with cast nephropathy benefited from few sessions of TPE. This study was scrutinized as many of the patients were never biopsied, so we don't know for sure we are treating cast nephropathy. At this point, perhaps a severe cast nephropathy biopsy proven on dialysis might benefit from TPE but there is no concrete evidence.

What about lupus Nephritis? The investigators in 2005 found, based upon a review of clinical trials, that the current use of cyclophosphamide combined with steroids remains the best option to preserve renal function in proliferative lupus nephritis. The authors found no benefit with addition of plasma exchange to cyclophosphamide or azathioprine plus steroids for mortality or end-stage renal failure. Some anecdotal evidence suggests the use of TPE in Lupus with TMA.